Vulvar biopsy reimbursement rates : International Journal of Women's Dermatology

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Editorial

Vulvar biopsy reimbursement rates

Kraus, Christina N. MDa,*; Edwards, Libby MDb,c

Author Information
International Journal of Women’s Dermatology: October 2022 - Volume 8 - Issue 3 - p e031
doi: 10.1097/JW9.0000000000000031
  • Open

What is known about this subject in regard to women and their families?

  • Overall, vulvar conditions are an underserved area and delay in treatment of certain inflammatory and neoplastic conditions can lead to scarring, pain, malignancy, and decreased quality of life.
  • Vulvar biopsies are performed by dermatology, gynecology, primary care providers, and other vulvar providers.
  • Very few studies have looked at vulvar biopsies, and none have looked at reimbursement rates.

What is new from this article as messages for women and their families?

  • Vulvar biopsies are reimbursed at the lowest rates (price and work relative value units) of all special site biopsies based on Medicare data.
  • Vulvar biopsies are reimbursed at about half the rate of penile biopsies (vulva: $97.35, wRVU 1.1 wRVU; penis: $209.36, wRVU 1.90).
  • We highlight these findings to increase dialogue on differing reimbursement rates for genital site skin biopsies with the aim of advocating for more congruous genital biopsy reimbursement.

Vulvar disease is an underserved area in medicine.1 Early diagnosis and treatment can prevent scarring, malignancy, sexual dysfunction, pain, and disfigurement, as well as improve quality of life outcomes. Vulvar dermatoses often present with nonspecific clinical findings and tissue biopsy can facilitate accurate diagnosis of inflammatory skin disease as well as evaluate for malignancy. A study in the Medicare population found that between 2000 and 2015, the annual number of skin biopsies increased by 142%.2 Specific codes exist for special site biopsies such as the nail unit, ear, eyelid margin, and genitalia. Herein, we comment on skin and mucosal biopsy reimbursement rates to highlight the lower reimbursement levels for vulvar biopsies based on Medicare payment data.

The vulva consists of keratinized squamous epithelium, as well as the modified mucous membranes and true mucous membranes, and, by definition, is composed of skin and mucosa.3 The vulva can be a technically difficult site to biopsy in terms of preparation and procedure. Vulvar disease is often associated with significant psychosocial and sexual comorbidities and optimal technique includes making sure the patient is knowledgeable about the procedure prior to proceeding and in a position that is comfortable for the patient, while being conducive to the provider obtaining the biopsy. Vulvar biopsies are challenging due to vulvar architecture. The skin and mucosa can be moist, thin, and difficult to apply traction too. Additionally, care must be taken to prevent crushing the tissue, which can be more prone to injury, particularly when inflamed.

Despite these challenges, reimbursement for a vulvar biopsy is the lowest of all special site biopsies with a nonfacility price of $97.35 (work Relative Value Units [wRVU] 1.1) (Table 1).4 We utilized the Physician Fee Schedule from 2021 for the Medicare codes for skin biopsy and special site biopsies. The data included in the National Payment Amount from the Centers for Medicare and Medicaid Services data.4 We focus on the nonfacility fee that is more frequently used in the outpatient dermatology setting. Other mucosal site biopsies include lip and penile biopsies. A lip biopsy is reimbursed at a nonfacility price of $128.76 (wRVU 1.22). Moreover, a penile biopsy is reimbursed at the highest rate of all skin and mucosal biopsies (nonfacility price of $209.36; wRVU 1.90). The penis is made up of the same type of epithelium as the vulva—keratinized, stratified squamous epithelium and mucosa (glans penis). One may argue that if the glans penis (a mucosal surface) is biopsied, the reimbursement rate should be equivalent to that of a mucosal lip biopsy, which is still reimbursed at a lower rate than a penile biopsy and a higher rate than a vulvar biopsy.

Table 1. - Medicare pricing information for single HCPCS codes with national payment amount (2021, CMS.gov.)
Procedure CPT Nonfacility price (USD) Facility price (USD) Work RVU
Vulvar/perineal biopsy 56,605 97.35 60.71 1.10
Penile biopsy 54,100 209.36 122.82 1.90
Lip biopsy 40,490 128.76 70.83 1.22
Tangential biopsy, single skin lesion 11,102 106.42 38.03 0.66
Punch biopsy, single skin lesion 11,104 133.29 48.15 0.83
Nail unit 11,755 130.15 62.11 1.25
Ear 69,100 101.54 51.84 0.81
Eyelid margin 67,810 192.96 69.44 1.18
CMS, Centers for Medicare and Medicaid Services; CPT, Current Procedural Terminology; HCPCS, Healthcare Common Procedure Coding System; RVU, Relative Value Units; USD, United States Dollar.

It is important to offer examination of the vulva during skin exams. Overall, women, transgender men, and nonbinary patients with vulvas receive delayed care,5 and dermatologists are uniquely poised to care for vulvar skin. One survey study found that 18% of academic dermatologists and dermatology resident respondents were not comfortable performing vulvar biopsies.6 Increasingly, efforts are being made to recognize and implement education on vulvovaginal disease and comfort with vulvar biopsies.7 Part of leading these changes, includes acknowledgment of the existing disparity in genital skin reimbursement rates and a call to action for revision.

In summary, we believe vulvar biopsy reimbursement rate should be reevaluated, and we advocate for changing vulvar biopsy reimbursement to be congruous with that of other mucosal biopsy reimbursement.

Conflicts of interest

None.

Funding

None.

Study approval

The author(s) confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies.

References

1. Mauskar MM, Marathe K, Venkatesan A, Schlosser BJ, Edwards L. Vulvar diseases. JAAD 2020;82(6):127784.
2. Wang DM, Morgan FC, Besaw RJ, Schmults CD. An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015. J Am Acad Dermatol 2018;78:47–53.
3. Edwards L, Lynch PJ. Genital dermatology Atlas. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins2012.
4. Centers for Medicare & Medicaid Services. HCPCS–General Information. 2021. Available from: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/MedHCPCSGeninfo/. Accessed September 22, 2021.
5. Gardner IH, Safer JD. Progress on the road to better medical care for transgender patients. Curr Opin Endocrinol Diabetes Obes 2013;20(6):553–8.
6. Panez S, Sattler S, Dobry AS, Kraus CN. A survey of practices and perceptions of vulvar biopsies in academic dermatology. Int J Womens Dermatol 2021;7(5Part B):763–5.
7. Comstock JR, Endo JO, Kornik RI. Adequacy of dermatology and ob-gyn graduate medical education for inflammatory vulvovaginal skin disease: a nationwide needs assessment survey. Int J Womens Dermatol 2020;6(3):182–5.
Keywords:

Biopsy; vulvar

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Women’s Dermatologic Society.